SAEM Clinical Image Series: Painful Blue Arm

By |Categories: Cardiovascular, SAEM Clinical Images|

A 68-year-old male with a past medical history of hypertension, hyperlipidemia, and recent ileostomy secondary to small bowel obstruction presented for acute left arm swelling, discoloration, and numbness since last night. He endorses sudden onset of painful edema with the development of purple discoloration. He denies trauma, history of similar problems, chest pain, or shortness of breath. He endorses difficulty flexing at the elbow secondary to the amount of swelling, pain, and numbness to the arm. The patient had a peripherally inserted central catheter (PICC) line placed in the left upper extremity two weeks ago.   [+]

Balanced Fluids in Diabetic Ketoacidosis

By |Categories: EM Pharmacy Pearls, Endocrine-Metabolic, Tox & Medications|

Background Many guidelines and treatment algorithms for diabetic ketoacidosis (DKA) recommend sodium chloride 0.9% as the replacement fluid of choice, though alternative fluids may be a better option [1-4]. Randomized trials, in adult and pediatric patients, demonstrate faster resolution of DKA when using balanced solutions (e.g., PlasmaLyte-A, lactated Ringer's) compared to sodium chloride [5-7]. Dr. Josh Farkas provides further review of this topic in 3 excellent and detailed EMCrit posts [8-10]. Evidence A phase-2 study published in 2021, SCOPE-DKA, randomized 93 patients with severe DKA (median venous pH 7.0) to receive PlasmaLyte-148 (PlasmaLyte-A) or sodium chloride 0.9% [11]. During the first [+]

SAEM Clinical Image Series: Inguinal Masses

By |Categories: Genitourinary, SAEM Clinical Images|

A 50-year-old female with a past medical history of gastritis and marijuana abuse presents to the Emergency Department (ED) with epigastric abdominal pain for one day. The patient reports she was seen in the ED one month prior for similar symptoms and had an ultrasound of the gallbladder, which was negative. She was discharged home with prescriptions for Pepcid, Carafate, and Zofran. Once discharged home she did not experience any symptoms until the day prior to presenting again to the ED. The patient denies nausea, vomiting, back pain, dysuria, hematuria, subjective fevers, chills, diarrhea, vaginal bleeding, vaginal discharge, chest [+]

SAEM Clinical Image Series: I Have a Stomachache

By |Categories: Gastrointestinal, Pediatrics, SAEM Clinical Images|

An 18-year-old male with no significant past medical history presents with diffuse abdominal pain and multiple episodes of non-bloody, non-bilious vomiting for three days. The patient was seen yesterday at another facility and states he was diagnosed with gastritis and discharged with Zofran, which provided no relief. He denies fever, diarrhea, or urinary symptoms and states his last bowel movement was two days ago and was consistent with his usual bowel movements.     Vitals: T 97.7ºF; HR 138; BP 122/98; RR 18; O2 sat 99% on RA General: Thin male, appears uncomfortable Abdominal: Mild distention [+]

SAEM Clinical Image Series: Vomiting in the Pediatric Patient

By |Categories: Gastrointestinal, Pediatrics, SAEM Clinical Images|

A 2-year-old boy with a past medical history of Hirschsprung disease presents to the emergency department (ED) with vomiting, abdominal distension, and inability to tolerate PO for one day. His parents had been instructed by their pediatric surgeon to perform rectal irrigations 2-3 times daily for the few days prior to presentation.   Vital signs within normal limits. General: Appears lethargic HEENT: Oral mucosa dry Abdomen: Moderately distended; decreased bowel sounds Skin: Normal turgor Non-contributory The differential diagnosis for pediatric patients presenting with vomiting is broad and includes but is not limited to gastritis, [+]

SAEM Clinical Image Series: Painful Weeping Rash

By |Categories: Dermatology, SAEM Clinical Images|

A 67-year-old nontoxic appearing male patient with a history of coronary artery disease, hyperlipidemia, transient ischemic attack, gout, renal colic, and squamous cell carcinoma presents with concern for multiple new painful lesions on his body. The rash first appeared five months ago but disappeared for some time before reappearing. It has worsened over the past few weeks. He has pain, erythema, pruritus, and urticarial, blistering, crusted lesions. He has had clear drainage from ruptured blisters. His only recent change in medication is an increase in his allopurinol (initiated four months ago; increased three weeks ago). He has tried Benadryl [+]

Dose Order Matter? Which Antibiotic to Give First for a Bloodstream Infection

By |Categories: EM Pharmacy Pearls, Infectious Disease|

Background Early antibiotics are recommended for treatment of many infections, including patients with sepsis or septic shock [1]. Critically-ill patients and those with a suspected infection at risk for severe illness are generally administered two (or more) empiric antibiotics in the emergency department (ED) which cover a wide range of potential pathogens. A typical approach includes utilizing a broad-spectrum antibiotic (frequently a beta-lactam such as cefepime or piperacillin-tazobactam) plus an anti-MRSA agent (typically vancomycin). Early in the patient's hospital stay they may have limited IV access, so the question often arises as to which antibiotic to give first, the broad-spectrum [+]

ALiEM AIR Series | OB/Gyn 2021 Module

By |Categories: Approved Instructional Resources (AIR series)|Tags: , |

Welcome to the AIR OB/Gyn Module! After carefully reviewing all relevant posts from the top 50 sites of the Social Media Index, the ALiEM AIR Team is proud to present the highest quality online content related to OB/Gyn emergencies in the Emergency Department. 8 blog posts met our standard of online excellence and were curated and approved for residency training by the AIR Series Board. We identified 2 AIR and 6 Honorable Mentions. We recommend programs give 4 hours (about 30 minutes per article) of III credit for this module. AIR Stamp of Approval and Honorable Mentions In an effort to truly emphasize [+]